Orthopedic Coding Alert

Answer: Although it might be uncommon for a person to exhibit bruising without a discernible cause, it’s within the realm of possibility. Certain medical conditions and medications can cause the blood to thin significantly, leading to a heightened susceptibility to bruising. This can even result in bruising without any recognized traumatic event.

If this is indeed the case, you should report R23.3 (Spontaneous ecchymoses). You can use this for bruises larger than 1 cm; you can also use this code for bruises less than 3 mm (called petechiae). Contusions less than 1 cm but larger than 3 mm are known as purpura and are coded to D69.- (Purpura and other hemorrhagic conditions).

If it is not the case and your provider does confirm that the contusion was caused by a trauma, then you would look to S90.32- (Contusion of left foot), using the placeholder X and 7th character A, D, or S to describe whether the encounter was initial, subsequent, or sequela. You should also follow this code with an external cause code from Chapter 20 to describe how the injury occurred.

According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC, in Bella Vista, Arkansas, this is a scenario when you will need to query your orthopedist to determine the most specific code for the diagnosis. “It is important to identify not only the diagnosis but also the thought process for clarity and medical necessity. It is not in the scope for a coder to assess clinical responsibility. Physicians will need to be queried where a discernable code cannot be found,” says McNamara.